Anatomical variations of the biceps brachii insertion: a proposal for a new classification.

BACKGROUND: The biceps brachii (BB) muscle is one of the three muscles located in the anterior compartment of the arm. Its insertion consists of two parts. The first part - main tendon - attached in the radial tuberosity and the second part - lacertus fibrosus (LF) - in the fascia of the forearm flexors. The intention of research was to reveal the morphological diversity of the insertion of this muscle. Thanks to the results of this work, have been created a classification of the distal attachment of BB. The results of that research can be used to further develop surgical procedures in the given region. MATERIALS AND METHODS: Eighty (40 left, and 40 right, 42 female, 38 male) upper limbs fixed in 10% formalin solution were examined. RESULTS: We observed three types of the insertion of the BB. Type I was characterised by a single tendon and occurred most frequently in 78.75% of the examined limbs. The second most common type was type II which was characterised by a double tendon and was observed in 13.75% of all the limbs. The last and least common was type III which was characterised by three tendons and occurred in 7.5% of the examined limbs. Additionally, the type of LF was analysed. In 8 (10%) specimens it was absent, i.e. in 2 specimens with type II insertion and 6 specimens with type III (p = 0.0001). Therefore, it may be deduced that type III BB insertion tendon predisposes to LF deficiency. CONCLUSIONS: The BB tendon is characterised by high morphological variability. The new classification proposes three types of distal attachment: type I - one tendon; type II - two separated band-shaped tendons; type III - three separated band-shaped tendons. The presence of type III BB tendon predisposes to a lack of LF.

A guideline to medical photography: a perspective on digital photography in an orthopaedic setting.

PURPOSE: Quality photographs are essential for clinical documentation, research, and publication in scientific journals and teaching. Oftentimes, non-ideal lighting and a sterile environment restrict the medical photographer, resulting in lower-quality photographs. This article aims to provide a clear and comprehensible guideline for medical photography in an orthopaedic setting. METHODS: This article is based on extensive photographic involvement in operating and laboratory settings, in close collaboration with medical professionals from the Steadman Clinic (Vail, Colorado, USA), Gothenburg University (Göteborg, Sweden) and Erasmus MC (Rotterdam, the Netherlands). Background literature was searched through Google Scholar and PubMed. RESULTS: Three relevant journal articles, and one book on medical photography, were used to write this paper. Seventeen Internet articles were used for background information. CONCLUSION: A relevant, up-to-date and comprehensive guideline to medical photography for medical professionals, with or without photographic experience, is provided. LEVEL OF EVIDENCE: Expert opinion, Level V.

Articular cartilage injuries of the knee: evaluation and treatment options.

Articular cartilage defects of the knee can be very debilitating, and diagnosis can be difficult because the symptoms are often nonspecific. Routine MRI scans, despite vast improvement in detection techniques, are often not sensitive or specific enough, especially for low-grade lesions. Therefore, articular cartilage injuries of the knee are often a diagnosis of exclusion requiring a thorough history, a good physical exam, and a high index of suspicion. Treatment of these injuries is still evolving, but new treatment options, including autogenous chondrocyte implantation, look promising, and long-term outcomes, while not yet complete, look encouraging.

Cervical spine alignment in the immobilized ice hockey player. A computed tomographic analysis of the effects of helmet removal.

To determine if helmet removal causes a significant increase in lordosis of the cervical spine in ice hockey players, we radiographically assessed the position of the cervical spine in subjects immobilized to a standard spine backboard wearing shoulder pads both with and without a helmet. Ten adult male volunteers (ages, 18 to 28 years) with no previous history of cervical spine injuries were fitted with an appropriately sized ice hockey helmet and shoulder pads and immobilized in a supine position to a standard spine backboard. Computerized tomographic lateral scout scans were obtained of the cervical spine for three conditions: 1) no equipment (control), 2) helmet and shoulder pads, and 3) shoulder pads only (helmet removed). With the helmet removed and the shoulder pads remaining, a significant increase in C2 to C7 lordosis was found when compared with the other two conditions. Individual segmental measurements revealed a significant increase in cervical lordosis at the C6-7 level with the helmet removed compared with the helmet and shoulder pads condition. Our results demonstrate that the removal of an ice hockey helmet from a supine player causes a significant increase in lordosis (extension) of the cervical spine. We recommend that ice hockey helmets not be removed from injured players, with rare exceptions, because doing so results in unnecessary motion of the cervical spine.

The magnetic resonance imaging appearance of individual structures of the posterolateral knee. A prospective study of normal knees and knees with surgically verified grade III injuries.

The purpose of this study was to contrast the magnetic resonance imaging appearance of uninjured components of the posterolateral knee with that of injured structures, and to assess the accuracy of magnetic resonance imaging in identifying posterolateral knee complex injuries. Thin-slice coronal oblique T1-weighted images through the entire fibular head were used to identify the posterolateral structures in seven uninjured knees. The appearance of corresponding grade III injuries to these structures was identified prospectively in 20 patients and verified at the time of surgical reconstruction. The sensitivity, specificity, and accuracy of imaging for the most frequently injured posterolateral knee structures in this series were as follows: iliotibial band-deep layer (91.7%, 100%, and 95%), short head of the biceps femoris-direct arm (81.3%, 100%, and 85%), short head of the biceps femoris-anterior arm (92.9%, 100%, and 95%), midthird lateral capsular ligament-meniscotibial (93.8%, 100%, and 95%), fibular collateral ligament (94.4%, 100%, and 95%), popliteus origin on femur (93.3%, 80%, and 90%), popliteofibular ligament (68.8%, 66.7%, and 68%), and the fabellofibular ligament (85.7%, 85.7%, and 85.7%). Magnetic resonance imaging of the knee was accurate in the identification of these injuries.

The anterior intermeniscal ligament of the knee. An anatomic study.

The purpose of this study was to identify the presence of the anterior intermeniscal ligament of the knee and to study its attachment patterns and relationships to other anatomic structures within the knee. Fifty unpaired cadaveric knees were dissected. An identifiably distinct anterior intermeniscal ligament was found in 47 specimens (94%). The average length was 33 mm and the average midsubstance width was 3.3 mm. The average perpendicular distance from the anterior intermeniscal ligament to the anterior margin of the tibial insertion of the anterior cruciate ligament was 7.8 mm (range, 2.0 to 13.5). The anterior intermeniscal ligament was the primary attachment for the anterior horn of the medial meniscus in 12 knees (24%); 7 knees (14%) had no tibial insertion and 5 knees (10%) had only a fine fascial tibial connection. Successful arthroscopic evaluation, surgical repair, and meniscal allograft reconstruction can be enhanced by a precise knowledge of the anterior intermeniscal ligament anatomy, especially when identifying the various insertion patterns of the anterior horn of the medial meniscus. A correct understanding of these patterns is helpful for avoiding patient injury during surgical procedures (particularly arthroscopic ACL reconstructions) performed in close proximity to the anterior intermeniscal ligament of the knee.

The effects of grade III posterolateral knee complex injuries on anterior cruciate ligament graft force. A biomechanical analysis.

To determine if untreated grade III injuries of the posterolateral structures contribute to increased force on an anterior cruciate ligament graft, we measured the force in the graft in cadaveric knees during joint loading after reconstruction with otherwise intact structures and in the same reconstructed knees after selected cutting of specific posterolateral knee structures. Tests were first performed on the knee with the posterolateral structures intact and then after sequential sectioning of the fibular collateral ligament, popliteofibular ligament, and popliteus tendon. The graft force was significantly higher after fibular collateral ligament transection during varus loading at both 0 degree and 30 degrees of knee flexion than it was for the same loading of the joint with intact posterolateral structures. In addition, coupled loading of varus and internal rotation moments at 0 degree and 30 degrees of flexion further increased graft force beyond that with varus force alone. The increase in graft force remained significant with additional sequential cutting of the popliteofibular ligament and popliteus tendon. We believe this study supports the clinical observation that untreated grade III posterolateral structure injuries contribute to anterior cruciate ligament graft failure by allowing higher forces to stress the graft.

Acute Knee Injuries; On-the-Field and Sideline Evaluation.

An athlete who has an acute knee injury should be assessed rapidly on the field and then more thoroughly on the sideline or in the training room. On-the-field assessment includes questions about the mechanism of injury and any similar previous injuries, a visual check for knee deformities and skin injuries, a neurovascular exam, and, ideally, tests for flexion and hyperextension. On the sideline or in the training room, standard physical tests are likely to reveal any significant injuries. These include the patellar apprehension, Lachman, posterior sag, quadriceps active, posterior drawer, posterolateral drawer, valgus and varus stress, pivot-shift, and dial tests.

Winner of the AlbertTrillat Young Investigator Award. The effects of aggressive notchplasty on the normal knee in dogs.

We assessed the possible association between an aggressive intercondylar notchplasty and histopathologic, radiographic, and gait changes to the knee. Three groups of six adult greyhounds were observed for 6 months. Group I dogs had a sham operation. Group II dogs had a 4-mm notchplasty of the lateral femoral condyle where it articulates with the lateral tibial spine. Group III dogs had a 7- to 8-mm notchplasty of the lateral femoral condyle to simulate the long-term effects of an overly aggressive notchplasty. Force plate gait analyses were not significantly different for any dogs at 3 and 6 months. Histopathologic studies (hematoxylin and eosin and safranin O stains) revealed notchplasty area remodeling with a thin layer of lamellar bone covered by fibrous connective tissue. Both Group II and III dogs had significant loss of lateral femoral condyle and trochlear groove articular surface proteoglycans. The radiographic notch width index remained unchanged throughout the study for Group I; the indexes increased immediately after surgery in Groups II and III because of the notchplasty, but after 6 months these values returned to near-preoperative measurements. An aggressive intercondylar notchplasty caused articular cartilage histopathologic changes at 6 months consistent with those found in knees with early degenerative arthritis. Significant refilling of a non-impinged notchplasty occurred by 6 months after surgery. Our results raise concern about the effects of aggressive intercondylar notch widening in humans.

The anatomy of the deep infrapatellar bursa of the knee.

Disorders of the deep infrapatellar bursa are important to include in the differential diagnosis of anterior knee pain. Knowledge regarding its anatomic location can aid the clinician in establishing a proper diagnosis. Fifty cadaveric knees were dissected, and the deep infrapatellar bursa had a consistent anatomic location in all specimens. The deep infrapatellar bursa was located directly posterior to the distal 38% of the patellar tendon, just proximal to its insertion on the tibial tubercle. There was no communication to the knee joint. Its average width at the most proximal margin of the tibial tubercle was slightly wider than the average distal width of the patellar tendon. It was found to be partially compartmentalized, with a fat pad apron extending down from the retropatellar fat pad to partially divide it into anterior and posterior compartments. The recommended approach to this bursa, either for aspiration, injection, or surgery, is along the lateral edge of the patellar tendon just proximal to the tibial tubercle.

The reharvested central third of the patellar tendon. A histologic and biomechanical analysis.

We assessed the histologic, mechanical, and structural properties of the reharvested central-third patellar tendon in greyhounds. Twelve dogs had the central third of the patellar tendon (5 mm) removed with corresponding bone blocks from the patella and tibia; the remaining tendon defect was loosely closed. Six dogs were sacrificed at 6 months and six at 12 months, and the central third of the patellar tendon was harvested from both the operative and the contralateral control knees. Analysis of the structural changes in the tendons revealed a significant increase in thickness for reharvested tendons at both 6 and 12 months when compared with controls. The entire residual tendons were narrower at 6 months and were shorter at 12 months compared with controls. Mechanical testing showed that the average failure load, ultimate tensile strength, strain at failure, and average modulus for the reharvested central third of the patellar tendon were significantly less than that of controls at both 6 and 12 months. Analysis of collagen fiber size by electron microscopy revealed a significant increase in collagen fiber diameter at 6 months (135 +/- 41 nm versus 49 +/- 4 nm) but no difference between the operative limbs and controls at 12 months. The reharvested bone-patellar tendon-bone complex does not have the same properties as the primary patellar tendon graft up to 1 year after harvest in a canine model, and its use for revision cruciate ligament reconstruction must be carefully reexamined.

Arthroscopic evaluation of the lateral compartment of knees with grade 3 posterolateral knee complex injuries.

The purpose of this study was to evaluate prospectively the arthroscopic findings in the lateral compartment of knees with posterolateral knee complex injuries, to help identify individual injured anatomic structures, and to assist in the clinical identification of these injuries. Thirty of 33 consecutive knees noted to have grade 3 posterolateral knee complex injuries on preoperative evaluations and examinations under anesthesia underwent arthroscopic evaluation concurrently with open reconstruction. The arthroscopic evaluation revealed a significant number of pathologic changes in the lateral compartment that may have gone undetected if only an open reconstruction had been performed. Tears were identified arthroscopically in 25 (83%) of the anteroinferior, 22 (73%) of the posterosuperior, and 14 (47%) of the posteroinferior popliteomeniscal fascicles. Injuries to the coronary ligament (80%) and meniscotibial portion of the midthird lateral capsular ligament (73%) were also frequently seen. Other structures injured included the meniscofemoral portion of the posterior capsule (37%), the ligament of Wrisberg (33%), and the meniscofemoral portion of the midthird lateral capsular ligament (10%). Ten avulsions (33%) of the popliteal tendon origin off the femur were also identified. Identification of these injured components greatly facilitated open reconstruction of injuries to the posterolateral complex of the knee. All 30 knees were noted to have greater than 1 cm of lateral joint laxity with application of a varus stress. When an unexpected amount of lateral joint laxity is seen arthroscopically (a "drive-through" sign) in a patient with suspected ligamentous instability, one should consider a diagnosis of posterolateral knee complex injury.

The fibular collateral ligament-biceps femoris bursa. An anatomic study.

The anatomy of the fibular collateral ligament-biceps femoris bursa is described. The bursa is located lateral to the distal quarter of the fibular collateral ligament and forms an inverted "J" shape around the anterior and anteromedial portions of the ligament. Its most distal margin is just proximal to the fibular head where the fibular collateral ligament inserts, and its more proximal aspect is at the superior edge of the anterior arm of the long head of the biceps femoris muscle. We found this structure in all 50 knees dissected; there was a constant anatomic location of the fibular collateral ligament-biceps femoris bursa in all specimens. Measurement of the anatomic dimensions of the bursa revealed a mean width of 8.4 mm and a mean height of 18 mm. Knowing the prevalence, shape, size, and anatomic location of this bursa may aid the clinician in the differential diagnosis of lateral knee pain.

Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability.

Seventy-one consecutive patients with posterolateral knee injuries had clinical stability testing abnormalities documented prospectively. We compared these findings with the incidence and patterns of their injuries documented at surgery. An abnormal reverse pivot shift test was associated with injury to the fibular collateral ligament (P = 0.01), popliteal components (P = 0.01), and midthird lateral capsular ligament (P = 0.02). An abnormal posterolateral external-rotation test at 30 degrees of flexion was associated with injury to the fibular collateral ligament (P = 0.0001) and lateral gastrocnemius tendon (P = 0.01). An abnormal adduction test at 30 degrees of flexion was associated with injury to the posterior arcuate ligament (P = 0.02). The results of this study should alert the clinician to the possibility of injury to a specific anatomic structure when the corresponding clinical stability test is abnormal. Because the fibular collateral ligament was injured in only 23% of the knees in this large series of patients, we recommend that an injury to the fibular collateral ligament not be the sole determining factor in making the diagnosis of posterolateral injuries. The wide array of injuries to many individual anatomic components that we found indicates the complexity of injuries to the posterolateral aspect of the knee.

The posterolateral aspect of the knee. Anatomy and surgical approach.

Thirty cadaveric knees were dissected to obtain a detailed understanding of the anatomic structures of the posterolateral aspect of the knee, and a dependable surgical approach to evaluate injuries to these structures was developed and used on 71 consecutive patients who were operated on for posterolateral knee injuries. Three fascial incisions and one lateral midcapsular incision were used to provide surgical access. The following individual anatomic structures were identified: the layers of the iliotibial tract, long and short heads of the biceps femoris muscle, fibular collateral ligament, midthird lateral capsular ligament, fabello-fibular ligament, posterior arcuate ligament, popliteus muscle complex, lateral coronary ligament, and posterior capsule. This study increased our understanding of the individual anatomic structures and the relationships between these components. The surgical approach provided for the evaluation of these anatomic structures should aid the surgeon in properly assessing the injuries before surgical repair. This information should also stimulate more anatomic, biomechanical, and clinical studies of the posterolateral aspect of the knee.

The biceps femoris muscle complex at the knee. Its anatomy and injury patterns associated with acute anterolateral-anteromedial rotatory instability.

We dissected 30 cadaveric knees to provide a detailed anatomic description of the biceps femoris muscle complex at the knee. The main components of the long head of the muscle are a reflected arm, a direct arm, an anterior arm, and a lateral and an anterior aponeurosis. The main components of the short head of the biceps femoris muscle are a proximal attachment to the long head's tendon, a capsular arm, a confluens of the biceps and the capsuloosseous layer of the iliotibial tract, a direct arm, an anterior arm, and a lateral aponeurosis. We examined 82 consecutive, acutely injured knees with clinical signs of anterolateral-anteromedial rotatory instability for the incidence and anatomic location of injuries to the biceps femoris muscle. Injuries to components of that muscle were identified in 59 (72%) of these knees; 29 knees (35.4%) had multiple components injured. There were 3 injuries to the long head of the biceps femoris muscle (all in the reflected arm) and 89 to the short head. A statistically significant correlation (P = 0.01) was found between increased anterior translation with the knee at 25 degrees of flexion as demonstrated by the Lachman test and injury to the biceps-capsuloosseous iliotibial tract confluens. Additionally, adduction laxity at 30 degrees of flexion correlated with a Segond fracture (P = 0.04). These data establish, in part, the relationship of the biceps femoris complex injury to anterior translation instability.